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The ISMA makes progress with Anthem dispute and with state’s insurance complaint process
e-Reports, December 27, 2010
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Last year, the ISMA filed a national compliance dispute against Anthem/Wellpoint in response to ISMA members’ massive claims payment and processing problems. According to Anthem, those resulted largely from a failed computer system migration for its Blue Card Program.

The ISMA and Anthem mutually agreed to mediate the dispute; a third mediation session occurred Nov. 30. “Due to a confidentiality agreement, the ISMA is not permitted to discuss specifics about the mediation,” said Julie Reed, ISMA legal counsel. “However, we will be permitted to discuss the terms of any future settlement we reach.”

The compliance dispute process was created in 2005, part of the settlement of class action lawsuits against most major commercial payers. The compliance dispute offered a way of ensuring Anthem follows the business practices required in the settlement agreement. The action is not a lawsuit.

Find background about the Anthem claims issue on the ISMA website.

Progress with insurance department

When the Anthem computer system problems occurred, claims quickly piled up. And when the claims piled up, so did the complaints to the Indiana Department of Insurance (IDOI).

In fact, the ISMA hired an outside vendor to scan all complaints filed against Anthem over an 18-month period. “Analysis of those complaints revealed a significant spike in the number of IDOI complaints filed in those 18 months compared to a previous similar time period,” noted Mike Rinebold, ISMA’s director of Government Relations.

The ISMA met several times with the insurance commissioner and several of his deputies. Days prior to the first meeting, the IDOI revised its provider complaint form, instituting a new complaint filing threshold of $250 for doctors and $5,000 for hospitals.

“If the $250 threshold were in place during the Anthem computer snafu, a significant number of complaints would have been rejected, leaving physicians few options to find help with their complaints,” Rinebold explained.

The ISMA asked the IDOI to restore physicians’ parity with consumers by removing that complaint threshold amount and allowing doctors and hospitals to file complaints electronically. Because of leadership changes at the IDOI, the ISMA was unable to make immediate progress on the complaint process.

At the 2009 Convention, ISMA Past President David Welsh, M.D., introduced Resolution 09-10 seeking legislation to remove the threshold filing amount and allow electronic filing.

“Before seeking a bill, the ISMA discussed the issue with many legislators and held multiple meetings with the new insurance commissioner, Steve Robertson, and his deputies,” said Rinebold. “Commissioner Robertson has been very fair; he’s willing to meet with us, hear our concerns and take action when he thinks it’s appropriate.”

Ultimately, a bill was unnecesary.

Positive changes for you

The commissioner did agree to remove the complaint filing threshold of $250 as well as the 90-day waiting period for filing complaints, and his department created a complaint form that can be filed electronically instead of by fax or mail.

“We were pleased to see the new form is streamlined,” noted Rinebold. “It does not require submission of additional information or attachments and can be submitted in one click.”

The IDOI reminds you it is critically important to carefully review a patient’s insurance card and accurately submit relevant information on the complaint form. Failure to accurately provide requested information could cause your complaint to be delayed or rejected.

Also, the IDOI advised it does not have jurisdiction over self-funded plans, which fall under the federal ERISA law and the U.S. Department of Labor. However, the IDOI does have jurisdiction over fully insured plans and third-party administrators (TPAs). Also note the IDOI has no jurisdiction over out-of-state plans, but you can likely file a complaint with the state insurance department where a particular policy was issued.

You are encouraged to first try resolving any dispute with the payer. If unsuccessful, you can utilize the IDOI’s complaint process; see here.

“With improvements secured through the ISMA’s efforts, the IDOI complaint process should now prove more efficient and accessible,” said Rinebold.

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